Transforming Pediatric Mental Health Care

What is the team at Children's Hospital Colorado doing to change mental health care in Colorado and beyond?

Nationally, there’s no shortage of sobering numbers related to pediatric mental health. According to the Centers for Disease Control and Prevention, one in five kids are living with a mental health condition, and 42% of students feel persistently sad or hopeless. In 2021, one in five kids seriously considered suicide and 10% made a suicide attempt. In fact, in Colorado, suicide is the leading cause of death for individuals between 10 and 24, and in 2022, Children’s Colorado saw a 63% rise in kids visiting emergency departments for mental health concerns.

Addressing the mental health care crisis

For more than a decade, mental health care providers have watched numbers like these grow. But during the COVID-19 pandemic, a new awareness began to grow, too. Since joining Children’s Colorado in 2021, Ron-Li Liaw, MD, child psychiatrist and inaugural Mental Health-in-Chief, has been working to capitalize on this moment of change and build infrastructure designed to make a measurable and meaningful impact.

Dr. Liaw’s work started with an exploration of root causes. They weren’t hard to identify. Compared to 2007, Colorado now has 2,000 fewer available beds in residential and inpatient mental health care. That’s in part because the healthcare staffing shortages that have plagued the entire nation have been even more pronounced in mental health care. The U.S. Department of Health and Human Services estimates a deficit of 10,000 providers by 2025, and the Colorado Department of Healthcare Policy and Financing reports that nearly 40% of Coloradans live in areas with a shortage of behavioral health workers.

In the clinical setting, that’s resulted in monthslong waits for care, says Lyndsay Gaffey, Director of Patient Care Services in Children’s Colorado’s Pediatric Mental Health Institute.

“I’m really worried about kids who have a mental health condition that is treatable, is well known, and yet they are not able to access care,” Gaffey says. “Conversely, a subset of patients is in the hospital system because they have nowhere else to receive treatment at a lower level. These kids are in critical stages of development, getting messages that they’re untreatable, and they are suffering in these care settings.”

A trauma-informed approach and improved patient experience

Together with Jessica Hawks, PhD, Clinical Director in the Pediatric Mental Health Institute, and Sandra Fritsch, MD, Medical Director in the Pediatric Mental Health Institute, Gaffey and Dr. Liaw are working to set Children’s Colorado’s mental health care on a new course. Their efforts began in the hospital’s inpatient psychiatric unit. And while the foursome initiated this project, one of the first steps was to adopt a shared governance model that engages team members in driving and implementing change.

“In the last year, we’ve completely transformed the model so that we are a trauma-informed care team and care system,” Dr. Liaw says. “We are evidence-based, using the Unified Protocol for Emotional Disorders for Children and Adolescents, which is a transdiagnostic treatment that can be flexibly used with a variety of youth mental health concerns. So, patients could come in with depression, anxiety, trauma, disruptive behaviors, and this intervention has proven outcomes for helping them get better.”

To implement a trauma-informed approach, the entire team took 16 hours of training built around the idea of resilience and reframing mental health care not as, “What’s wrong with this patient?” but rather, “What’s happened to this patient, and why does this behavior make sense?” They now hold monthly clinical calls to realign on trauma-informed care and best practices, including reduced use of restraints and seclusion. Although the unit still has a seclusion room, since the change, it hasn’t been used once.

In addition to changing the ethos behind the unit’s approach to care, the team also made physical changes. The entire space was recently redesigned to better promote healing. Instead of an open space with little privacy, kids now stay in light, bright “neighborhoods,” and are matched together according to age and development. They also now wear their own clothes instead of scrubs, and now families are able to sleep on the unit so they can be close by and remain engaged.

“The whole tone on the unit is different. I think the patients feel that attunement with team members and understand that we are here to help them find their strength and capitalize on their resiliency,” Gaffey says. “If we can provide care that is trauma-informed, welcoming, transformative — that has a long-term, lasting impact on their trajectory in life.”

Already the unit has seen an increase in its workforce, a reduction in burnout and a 90% drop in use of restraints and seclusion. What’s more, the team has reduced team member injuries by 80%.

Strategic plan for mental health care research and trauma-informed care

Of course, the inpatient unit is just one piece of a massive puzzle. Dr. Liaw and a collaborative team with representatives from clinical care, a family advisory council, government affairs, executive leadership and more, worked together to build a five-year strategic plan for mental health care at Children’s Colorado. Their work aims to address access and care issues from early prevention through outpatient services, crisis and acute care, and community-based services.

In the outpatient setting, Dr. Liaw and her team are focused on expanding access to evidence-based specialty care, with the goal of tripling access to care for kids in Colorado over the next five years. To do this, Children’s Colorado will introduce seven new specialty outpatient clinics covering conditions that include anxiety, mood disorders, eating disorders, disruptive behaviors, early childhood mental health, medically complex and functional disorders, and neurodevelopmental disorders.

This model aims to improve access to care by connecting patients to the most effective and least resource-intensive treatment option. For example, most patients and families will engage in group-based services as first-line treatment. Additionally, as part of this outpatient expansion, the team will offer intensive outpatient programming across specialty clinics to eliminate gaps in the care continuum, with the goal of preventing the need for higher acuity services.

Dr. Liaw recognized that expanding access to care would also be crucial for kids in need of acute ambulatory care services. As a result, the team increased capacity in Children’s Colorado’s Eating Disorders Program and Partial Hospitalization Program (in which kids spend most of the day receiving treatment before heading home) by more than 50%, while also implementing a transdiagnostic, evidence-based care model.

And for kids experiencing mental health crises, the team is taking a three-pronged approach to clinical care: creation of rapid access in the ambulatory setting; enhancement of triage and assessment in the emergent setting; and creation of acute stabilization services. Together, these three clinical services will ensure kids receive mental health care tailored to their needs and have options beyond the emergency department for crisis care.

As part of this work, the team will develop an integrated, split-flow care pathway to better direct patients to the right level of care. This new pathway will continue to allow access to inpatient-level services when needed, while providing two new options outside of emergency settings. The first is a new sub-acute, stabilization unit offering family-centered crisis intervention for patients who are not well enough to go home after their initial emergency visit. The second is a new, ambulatory-based crisis clinic designed to provide rapid access to mental health services and connect patients to community providers and resources for follow-up care.

These clinical improvements at both the outpatient and inpatient levels, combined with a plethora of prevention strategies, robust community partnerships, new career pathways, advocacy at the local and national level, and a deep bench of research studies, come together to offer a bright path through a dense forest. And it couldn’t come at a better time.

“I’ve been in medicine for more than two decades, and this is the most I’ve ever seen mental health enter every conversation,” Dr. Liaw says. “This is our moment to capitalize on the awareness and the resources that are being put forth and the alignment at the national, state and local levels. That’s a powerful, collective voice and call to action.”

Key pediatric mental health research

One important aspect of improving mental health care in Colorado is research. At Children’s Colorado, more than 20 researchers are working to strengthen treatments by testing their efficacy in schools, primary care settings and hospitals. “Research contributes to a much larger understanding of what's happening in children's mental health, including what things are working, what things are not, what different populations might need, as well as identifying and addressing healthcare disparities,” says Dr. Liaw. Learn about three key studies below.